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The Eighth Circle of Fire E L A I N E W H I T F I E L D S H A R P , TLC ‘98 Junk science lurks in child abuse cases of every variety, whether they are alleged sexual molestation, or other physical and mental abuse cases. Parts I and II of this series covered the scientific flaws of a specific area of child abuse: so-called “shak- en baby syndrome” (SBS) cases, and the scientific flaws in short falls cases.1 This arti- cle2 will cover some of the ways to characterize and challenge those flaws in a pre- trial Daubert or Frye motion using the rules of evidence governing the admissibility of scientific evidence. (If you do not have a SBS case, you may still find the section on scientific evidence rules helpful because it applies not only to cases of alleged SBS, but to all scientific evidentiary issues in all civil or criminal cases.) To the extent that the judge agrees to exclude testimony that is not based on reliable science, testimony that is not based on the correct application of reliable science to a case, or testimony proposed by an ‘expert’ who is not qualified to give it, a pre- trial motion serves to: (1) possibly minimize the use of some of, if not all, unfairly prej- udicial testimony before a jury; (2) educate the trial judge that there are issues of junk science that are more unfairly prejudicial than probative; (3) flush out a refinement of the State’s theories on causation and timing of injury; (4) create an opportunity to discuss a possible plea by educating the State about the weaknesses in its scientific case; and/or (5) build a record for appeal on the junk science issues. As a matter of strategy, if you do not want to make a pretrial motion challenging the science, consider using the information in this article to help construct cross exami- nation for the purposes of moving for a directed verdict and/or motion to set aside the verdict in cases where the State relies predominantly on medical testimony to establish causation and timing.34 T H E W A R R I O R • S p r i n g 2 0 0 4

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Dante Alighieri with his Poems (detail), by Domenico di Michelino, c 1460. Dante placed the junk sci- entists of his time—alchemists and other deceivers of men—in the eighth circle of fire in Hell.C hild abuse is as ugly as it gets. The bruises on the swollen “My wife quit work because of this case.” faces and battered bodies of dead tots on the autopsy And, then there was this classic example of open-mindedness: table, the broken bones, the blood, the burns from irons,cigarettes and scalding water, might make you want to kill the Juror: “She’s guilty.”culprit. It might even be enough to make you believe the Judge: “Would evidence to the contrary make any differ-Devil actually exists. But the expert witness who brings junk ence to you?”science to the courtroom to assist in the wrongful convictions ofinnocent men or women is also enough to make you believe in Juror: “If I listened, probably not.”the ‘Father of Lies.’ Against this hostile backdrop, it is crucial to try to rewrite some of the established, predictable scenes by identifying unreliableReal child abusers and pseudo-science experts indulge in the science promoted by the State through expert testimony aboutsame vice: they abuse the power and trust we vest in them. In causation and timing of injury in SBS cases.“The Inferno,” Italian poet and philosopher Dante Alighieriplaced the pseudo-science deceivers of his day—diviners, magi- DEEP IN THE MOUTH OF THE WOLFcians and alchemists—in the eighth circle of fire in Hell. This area of practice is still as dark as the inside of a wolf ’sLike an accusation of witchcraft, a publicized child abuse accu- mouth, but paradigm shifts in law and medicine now empowersation is tantamount in the minds of many prospective jurors to us to try to bring in some light. In law, under Daubert v Merrella conviction. Many view a trial as just a Constitutional nicety Dow Pharmaceuticals3 and its progeny, the responsibility andbefore the inevitable conviction. Here are a few choice com- power to determine the reliability of scientific evidence has beenments from prospective jurors during voir dire in a so-called placed squarely in the trial judge’s hands.SBS case in which all but one of the 98 people on the venire had In medicine, physicians are now expected to ensure that theirread negative pretrial press reports about the case: diagnostic and treatment decisions are based on reliable science, “I am biased against child abusers.” that is, on evidence-based medicine (EBM) and not merely upon anecdotes and case reports. Evidence-based medicine “I feel she should be put away.” involves the use of well-designed studies of large numbers of “I’ve followed this from the start. She probably is guilty.” people to better guide treatment decisions. “I’ve got three kids of my own and when anger gets out of Both paradigm shifts are shifts in emphasis, from potentially hand, things happen.” unreliable to reliable information, representing an evolution in T H E W A R R I O R • S p r i n g 2 0 0 4 35

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THE EIGHTH CIRCLE OF FIREour attempt to increase trust in the system of justice and the thumb, for which we have James Alphonzo Frye4 to thank.practice of medicine. When we are responsible for the lives of Frye was on trial for murder and, to prove his innocence, or atothers in either the legal or medical arenas, the practice must be least to raise reasonable doubt, he took a systolic blood pressureas reliable as we can humanly make it. That is what is fair. That deception test, a crude precursor of the polygraph examination.is what is just. His defense lawyer offered the results of the test at trial and, SCIENCE GETS ITS DAY IN COURT when the trial judge sided with the government and refused to let the jurors hear the results, Frye’s attorney offered to bring theThe growth of science and technology leading up to and beyond ‘scientist’ who ran the test to run it again on the defendant rightthe Industrial Revolution has increasingly landed scientific in front of the jurors. Again, the trial judge ruled for the prose-issues in court at an exponential rate. Especially in the past 150 cutor and the jurors never heard that ‘scientific’ evidence.years, the courtroom has become the proving ground for manynew areas of science in order to determine criminal and civil Frye was convicted of second degree murder and, in a single-liability. issue appeal, he raised the question of whether, in excluding the evidence of the test, theOver the last two cen- trial judge abused histuries trial judges have discretion, creatingbeen asked to decide: reversible error that enti-Are there unique tled him to a new trial.human indentifiers,such as fingerprints? If Frye’s lawyer claimedso, are fingerprinting that the 1923 “deceptiontechniques reliable? Is test” measured systolicthe identification of a blood pressure, theperson through facial body’s strongest bloodmeasurement (anthro- pressure and that, bypometry) reliable? measuring changes inWhat about bite blood pressure triggeredmarks? Lip prints? by a witness’ changingVoice recognition? emotional state, the testHandwriting? Ear was able to detect truthprints? Is DNA typing or falsehood. Describingreliable? Is there a the underlying ‘scientif-machine that can tell if ic’ theory of the test, thesomeone is lying or Frye Court wrote:telling the truth? Is Scientific experi-there a machine that ments, it is claimed,enables us to see a per- have demonstratedson’s bones right that fear, rage andthrough their skin, pain always produce atheir brain, or injury to rise in systolic bloodtheir brain? Is there an pressure and that con- Junk science can seem like a laughing matter—until it is used against another humanobjective way to tell scious deception or being to take their liberty or life. Copyright, 2004 by Sidney Harris.how much pain a per- falsehood, conceal- Reprinted with permission.son suffered before ment of facts, or guiltdeath? How do we of crime, accompa-know if this bullet was discharged from this gun? nied by the fear of detection when the person is underExperts became a permanent fixture, and often as equally pow- examination, raises the systolic blood pressure curve, whicherful, as the trial judge’s gavel. Despite the widespread use of corresponds exactly to the struggle going on in the subject’sexperts on every subject from Antibodies to Zoology, most state mind, between fear, as the examination touches the vitaland federal trial court judges had few standards, if any, by which points in respect of which he is attempting to deceive theto independently judge the question: “Is this ‘science’ reliable examiner. In other words, the theory seems to be that truthenough for the trier of fact to consider in helping to resolve this is spontaneous, and comes without conscious effort, whilecase justly?” It is a maxim of our law that anything that is not the utterance of a falsehood requires a conscious effort,reliable is not relevant and, as such, may be more unfairly prej- which is reflected in the blood pressure.udicial than probative on issues that impact a finding of guilt or Although there were no guiding standards about what scientificinnocence. A lack of standards left judges adrift in uncertainty evidence should be admitted and excluded, a practice in someabout what to admit and what to exclude. courts in 1923 was to allow an expert to testify about scientificIn 1923, a federal appeals court announced a working rule of or technical knowledge when, in the judge’s discretion, the facts36 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIREneeded the interpretation or opinion of an expert to assist the data analysis, and otherwise intellectually corrupt orientationsjurors in understanding and deciding important issues in the and conclusions. Like any other human endeavor, science is farcase. from pure, neutral and unbiased.Confusion occurred when a party, like Frye, wanted jurors to Nevertheless, for more than 70 years, the Frye test held thehear scientific testimony about novel or cutting-edge “science.” world of law hostage to the idiosyncrasies of the world of sci-How was the trial judge to determine whether the “thing” that ence.was being proffered should be heard or considered by the trier But three relatively recent cases are designed to change all that.of fact? The United States Supreme Court laid out the rules for theThe Frye Court held that the standard was in the hands of the admissibility of scientific evidence in Daubert, Kumho andscientists, writing: Joiner. Just when a scientific principle or discovery crosses the line JASON DAUBERT AND THE SEARCH FOR RELIABILITY between the experimental and demonstrable stages is diffi- cult to define. Somewhere in this twilight zone the eviden- Jason Daubert and Eric Schuller were born with serious birth tial force of the principle must be recognized, and while defects. Because the boys’ mothers had taken the anti-nausea courts will go a long way in admitting expert testimony drug “Bendectin” during pregnancy, they blamed their sons’ deduced from a well-recognized scientific principle or dis- birth defects on the drug. The boys and their parents sued covery, the thing from which the deduction is made must Merrell Dow, the pharmaceutical company that made the drug. be sufficiently established to have gained general acceptance The company prevailed in a motion for summary judgment in the particular field in which it belongs.” Frye, 1014. when the trial judge found that the boys had no generally- (Emphasis added.) accepted evidence under Frye to take to a jury about what caused their birth defects. Juries resolve factual disputes andThe systolic blood pressure test had not gained the kind of here there was no dispute about causation because the plaintiffsstanding and recognition among physiologists and psycholo- had no evidence to create one, the court held.gists—the relevant scientific community—to warrant present-ing the results of the tests to jurors, the appeals court explained. Lawyers for Merrell Dow argued that all the human statisticalHolding that the trial judge had not abused his discretion, the studies about Bendectin showed the drug did not cause birthappeals court affirmed Frye’s murder conviction.5 defects. Lawyers for Jason and Eric argued that their evidence showed that Bendectin did cause the boys’ birth defects. TheyThus was born the test in the federal courts by which any evi- offered (1) “in vitro” (test tube) and “in vivo” (live animal) stud-dence that a litigant claimed was novel “science” was to be ies that found a link between Bendectin and malformations; (2)judged: If the scientists said it was generally accepted in the rel- pharmacological studies that showed chemical structures similarevant scientific community, the trier of fact could consider it to to the chemical structure of Bendectin that they claimed causedresolve factual issues in criminal and civil cases. While the Frye birth defects; and (3) a “re-analysis” of previously publishedCourt only addressed the question of novel scientific evidence, human statistical—i.e., epidemiological—studies. (The thirdlater courts extended the “general acceptance” test of admissi- type of proof is sometimes called “meta-analysis” or “data pool-bility to all scientific evidence.6 For 70 years, the “Frye test,” as ing.”)it became known, was the standard for judging all science in thefederal courts. Most state courts adopted the Frye test, although The trial court judge dismissed the case because, under the Fryesome adopted hybrids of the test that imposed a duty on the test, “scientific evidence is admissible only if the principle upontrial judge to independently assess the reliability of proffered sci- which it is based is ‘sufficiently established to have generalentific testimony.7 acceptance in the field to which it belongs.’”In an ideal world, if a scientific proposition has been generally Jason and Eric had no way to challenge the accuracy of Merrellaccepted in the relevant community, one would expect it to be Dow’s human statistical studies, the trial court found. Thebased on a well-reasoned hypothesis shown to be valid by reli- plaintiffs’ re-analysis or recalculation of those studies had notably designed research consisting of sufficiently reliable data, been available for review by the relevant scientific community inand subsequent tests validating initial results. And, one would order to be generally accepted. Therefore, the trial court found,expect that any expert testimony about the proposition in a spe- Jason’s and Eric’s animal-cell (test tube) studies, live-animalcific case would be the product of reliable methods and conclu- studies, and the chemical structure analyses, did not establish,sions that would be properly applied to the facts of the case. and could not be admitted to show, that Bendectin caused birthFrye’s admissibility test of “general acceptance in the relevant defects.scientific community” would have implicitly contemplated all Jason and Eric appealed to the United States Court of Appealsof these expectations because reliability in hypothesis formation, for the Ninth Circuit. That court agreed with the trial judge:study or experiment design, testing and interpretation of results, Without generally-accepted evidence of causation, an element ofhave historically been the hallmarks of trustworthy science. the plaintiff ’s claim, the trial judge was correct to dismiss theirBut that is an ideal world. In the real world, scientists are lawsuit.plagued by problems of ego, turf wars, the politics of scientific Jason and Eric appealed to the U.S. Supreme Court to reviewfunding, faulty hypothesis formation, poor study design, poor their case on the question of the correct standard to apply in T H E W A R R I O R • S p r i n g 2 0 0 4 37

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THE EIGHTH CIRCLE OF FIREdetermining what is reliable “science.” By this time, some of the they alone, were to be the gatekeepers of scientific truth at the13 federal circuit courts of appeal were in conflict over how to bar. If the trial judge determines that proffered scientific testi-answer this question. Should they use the “general acceptance” mony is reliable, the gatekeeper should admit it for the trier ofFrye test, or the rule of evidence enacted by Congress in 1975? fact to consider. Otherwise, the gatekeeper must exclude it.The 1975 version of the rule stated: Federal Rule of Evidence 104(a) states in part: “Preliminary If scientific, technical, or other specialized knowledge will questions concerning the qualification of a person to be a wit- assist the trier of fact to understand the evidence or to ness . . . or the admissibility of evidence shall be determined by determine a fact in issue, a witness qualified as an expert by the court….” [Emphasis added] This was a mandate, not a knowledge, skill, experience, training, or education, may choice. testify thereto in the form of an opinion or otherwise.” The Court explained that, in acting as gatekeepers of scientific Federal Rule of Evidence 702. (“Rule 702.”) (Emphasis knowledge, there are some hallmarks of reliable science for added.) which to look:How was this rule, enacted by Congress 52 years after Frye, to 1. Is the “thing” that is being proffered as scientific capable ofbe applied? Was Frye’s general-acceptance test part of it? Or was being tested, and has it been tested? Quoting 19th Centurythe rule independent of that? If Rule 702 was independent of philosopher Karl Popper,9 the Court wrote: “ScientificFrye, how were trial judges to interpret and apply the rule? methodology today is based on generating hypotheses and testing them to see if they can be falsified; indeed, thisDaubert presented not only an unusual conflict of evidence laws methodology is what distinguishes science from otherand a bitter battle of scientific experts, but also a classic conflict fields of human inquiry.”;of decisions among the 13 federal circuit courts of appeal. 2. Has the theory or technique been subjected to peer reviewThe U.S. Supreme Court took the case. and publication? (Publication is not the sine qua non ofIn a nutshell, the Supreme Court held that scientific evidence admissibility and, indeed, is only one component of peerdid not have to pass Frye’s general acceptance test as a precon- review. Sometimes what is published is not reliable, anddition for admissibility, that Rule 702 was the pertinent rule to sometimes that which is reliable is not published. But, pub-apply, but that an interpretation of the rule requires trial judges lication ensures “submission to the scrutiny of the scientif-to act as reliability gatekeepers to ensure that an expert’s testi- ic community,” and is a “component of good science, inmony rests both on reliable methods and conclusions and that part, because it increases the likelihood that substantiveit is actually relevant to the specific case. How the Supreme flaws in methodology will be detected.”);Court got there is another story, and an important one to 3. Is there a known or potential rate of error? (Do standardsunderstand in order to mount a pretrial attack on evidence that exist and are these maintained in the testing? This is impor-the State claims is “science,” or in order to choose one’s own sci- tant in relation to the validation of test results through theentific evidence wisely to meet the standards for admissibility. use of consistent standards and is part of good science.);The main question for the Court was, when Rule 702 speaks of and“scientific evidence” what does that term mean and by what cri- 4. Is the “thing” generally accepted? (Depending on the caseteria should a trial court judge the “science” in deciding the and type of proffered scientific testimony, it may be rele-question of admissibility? vant to identify a relevant scientific community and to determine the degree of acceptance within that communi-Educated with help from 22 amici briefs filed by several of the ty.) Daubert, 593-4.nation’s scientific leaders,8 the Supreme Court cobbled togethera definition of what it believes the term “scientific knowledge” The Daubert Court emphasized that the trial judge’s “focus, ofmeans in Rule 702. “Scientific knowledge,” said the Court: course, must be solely on principles and the methodology, not • Implies a grounding in the methods and procedures of sci- on the conclusions they generate.” ence; Determining whether the proffered science is reliable is only one • Implies a body of known facts, accepted on good grounds; part of the gatekeeper’s job, said the Court. The trial judge must • Implies that an inference or assertion is derived by the sci- also ensure that the scientific testimony is, in fact, relevant to entific method; and resolve a disputed issue in the case. There must be a “fit” • Does not imply that the subject of scientific testimony must between the science proffered and the facts of the case. Wrote be “known to a certainty” for, arguably, there are no certain- the Court: “Rule 702’s ‘helpfulness’ standard requires a valid sci- ties in science. (“Science is not an encyclopedic body of entific connection to the pertinent inquiry as a precondition of knowledge about the universe. Instead it represents a process admissibility.” For example, in a case in which a child is found for proposing and refining theoretical explanations about at autopsy to have died solely as a result of blunt impact to the the world that are subject to further testing and refine- head, evidence that the child died as a result of violent shaking ment.”) Daubert, 590-591. is not scientifically relevant.Under Frye, the scientists told us what was reliable and what Under Daubert, reliability and relevancy (fit) are the two guid-was not. But, under Daubert, the Court told the trial judges ing principles in the determination of whether to admit scien-that the determination of reliability was their duty. They, and tific evidence.38 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIREDaubert’s “check list” of four factors to consider in determining General Electric appealed to the U.S. Supreme Court, arguingif proffered scientific testimony should be admitted contem- that the standard of review on appeal when a trial judge excludesplated the specific type of science offered in that case. On the scientific evidence is whether they abused their discretion, thatplaintiff ’s side were meta-analyses, in vivo and in vitro studies is, whether the decision was manifestly erroneous in that itwhile, on the defendant’s side were epidemiological studies, that lacked any reasonable, factual foundation. Looking at the trialis, the study of large groups of people from which statistical cor- judge’s findings in that light would mean that it was not mani-relations may be shown. Daubert’s specific fact situation festly erroneous for him to exclude the plaintiff ’s proof of cau-involved relatively esoteric areas of science. sation because there was a factual basis for the finding that this failed to make the link between Joiner’s exposure to PCB’s andDaubert did not answer the questions of whether, and how, it his cancer.applied to other areas of expert knowledge, such as, engineeringand other applied sciences and technology. And, it was not clear The U.S. Supreme Court took the case and ruled that theby what standard appeals courts were to review a trial judge’s appeals courts were to apply the abuse of discretion standard todecision to admit or exclude scientific evidence. Was it a mere review a trial judge’s rulings to admit or exclude scientific evi-“abuse of discretion” standard under which reliance by the trial dence. Unless there was no factual basis for the trial court’s deci-judge on any facts to admit or exclude expert testimony would sion, it was to be left untouched. This development meant thatbe upheld? If so, that would mean that the decision of the trial not only was the power to determine scientific reliability in thejudge, who already had the power to act as reliability gatekeep- hands of the trial judge, but the trial judge’s ruling was to beer, would be virtually untouchable on appeal. Or was the stan- pretty much impregnable to attack on appeal.dard a more stringent one in which the appellate courts would The other question in Joiner was whether a trial judge had tocompletely review the trial judge’s evidentiary ruling to see take the word of an expert that scientific evidence was reliable.whether they disagreed with the lower courts’ findings? The Court held that the trial court does not have to rely on theThe Court answered these questions in Joiner and Kumho. ipse dixit—the say-so or bare assertion—of an expert exerting his authority as such. Rather, the trial judge must be the relia- JOINER AND THE NOT-SO, bility gatekeeper, scrutinizing not only conclusions, but also the SAY-SO OF THE EXPERT methods used by experts in reaching those. Affirming the trial judge’s exclusion of the plaintiff ’s proofs, the Court remindedJoiner claimed that while working as an electrician for General trial judges who holds the reins of reliability and relevancy:Electric, he developed small-cell lung cancer because of hisexposure to polychlorinated biphenyls (PCB’s) and their deriva- “[C]onclusions and methodology are not entirely distincttives, furans and dioxins, found in the coolant fluid in trans- from one another. Trained experts commonly extrapolateformers. from existing data. But nothing in either Daubert of the Federal Rules of Evidence requires a [trial] court to admitJoiner’s experts on causation relied on studies performed on opinion evidence that is connected to existing data only byinfant mice that developed tumors in their small air sacs after the ipse dixit of the expert. A court may conclude that therehighly-concentrated, massive doses of PCB’s were injected is simply too great an analytical gap between the data anddirectly into their stomachs and abdominal walls. In contrast, the opinion offered.” Joiner, 146.Joiner’s human exposure was indirect and on a much lowerscale. Joiner’s experts also relied on two studies, the authors of Both Daubert and Joiner involved “scientific knowledge.” Thewhich, themselves, were unwilling to suggest a link between question still nagging the federal trial bench was whether thePCB’s and lung cancer. They also relied on a third study in trial judges had to be the reliability gatekeepers in all areas ofwhich a link between lung cancer and a specific mineral oil—to knowledge, such as skills-oriented, applied sciences like engi-which Joiner had not been exposed—was found. The trial judge neering. Did the duty extend to testimony based on “technical”ruled that this testimony was inadmissible because it did not or “other specialized” knowledge, as included in Rule 702?show that Joiner’s small-cell lung cancer was caused by his expo-sure to PCB’s and his experts’ testimony to the contrary, and KUMHO AND THE TIRED-TIREtheir insistence that causation was shown, did not rise above In Kumho, the U.S. Supreme Court answered the question. Insubjective belief or unsupported speculation. that case, one plaintiff had been killed and others injured whenThe Court of Appeals for the Eleventh Circuit disagreed. Rather a tire of the minivan they were traveling in blew out. The plain-than simply deciding whether the trial court had abused his dis- tiffs’ tire-failure-analysis expert inspected the tire and opinedcretion in coming to a manifestly erroneous factual conclusion, that the blow out was consistent with a tire-manufacturingthe Eleventh Circuit applied a stringent review. It held that, in defect and not due to wear and tear. But, he also conceded that the tire was old and worn and that it had twice previously beenlight of the fact that the rules of evidence display a preference punctured and inadequately repaired.for admissibility, the trial judge had incorrectly excluded theplaintiff ’s proof of causation. The trial judge had incorrectly Applying all four of the Daubert factors, the Kumho trial judgeplayed “science” judge by reaching a different conclusion about found that the testimony of the tire-expert witness on the causethe research than the plaintiff ’s experts reached. The jury, not of the blow out was not reliable, and dismissed the suit onthe judge, should decide between competing views of science, grounds that the plaintiffs could not prove the element of cau-the Eleventh Circuit said. sation. The plaintiffs moved for reconsideration on the grounds T H E W A R R I O R • S p r i n g 2 0 0 4 39

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THE EIGHTH CIRCLE OF FIREthat the trial judge too rigidly applied the Daubert factors. They [That] list was meant to be helpful, not definitive. Indeed,argued that these factors were to be used for areas of science akin those factors do not all necessarily apply even in everyto that in Daubert and that the real focus was not on the four instance in which the reliability of scientific testimony isfactors but on reliability. The Kumho trial judge reconsidered challenged. It might not be surprising in a particular case,using reliability as the standard, after which he wrote that “the for example, that a claim made by a scientific witness hascomponent of [the expert’s] tire failure analysis which most con- never been the subject of peer review, for the particularcerned the Court [was] the methodology employed by the application at issue may never previously have interestedexpert in analyzing the data obtained in the visual inspection, any scientist. Nor, on the other hand, does the presence ofand the scientific basis, if any, for such an analysis.” He did not Daubert’s general acceptance factor help show that anbuy that the plaintiffs’ expert’s tactile or hands-on inspection of expert’s testimony is reliable where the discipline itself lacksthe tire was reliable. reliability…” Kumho, 150-1.On appeal, the Eleventh Circuit Court of Appeals held in the The Kumho Court also warned against litigation bias in tests.plaintiffs’ favor on grounds that the Daubert factors only apply Expert witnesses must use the same degree of intellectual rigorto “scientific knowledge” and not to “technical” or other areas of in testing for a court case as they would in the laboratory, or any“specialized knowledge” in Rule 702. Kumho Tire appealed to other area of their practice. Methods and conclusions had to bethe U.S. Supreme Court. reliable in all contexts.The Supreme Court took the case “in light of the uncertainty” Here’s the sum and the substance of expert witness testimony:about whether Daubert applies to all areas of knowledge listedin Rule 702, i.e., science, technology and other specializations. • Daubert: The trial judge is the mandated gatekeeper of sci-The Court held it did. And, as for Daubert’s four factors, the entific reliability and relevancy. “Scientific knowledge” hasCourt wrote: certain hallmarks that make it reliable. All scientific expert testimony must be relevant to resolve an issue in the case “[I]n our view…we can neither rule out or rule in, for all (fit). cases and for all time the applicability of the factors men- • Joiner: A trial judge’s decision to admit or exclude scientific tioned in Daubert, nor can we now do so for subsets of expert testimony will only be upset by the appeals court if it cases categorized by category of expert or by kind of evi- is an abuse of discretion, i.e., without facts to support it. The dence. Too much depends upon the circumstances of the trial judge will usually have the last word. The trial judge particular case at issue.” does not have to take the word, i.e., the ipse dixit, of the ***** expert that a conclusion is correct if the methodology is Especially in the past 150 years, courts have become the proving ground for many new areas of science used to determine civil and criminal liability. They have answered questions about whether there are unique identi- fiers such as anthropometrics (unique facial measurements) fingerprints, and DNA. In the construction of reliable identification systems, "arrested men often put up such resistance to photography that they had to be held by force [before] the camera." Thorwald, J., “The Century of the Detective."40 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIRE unreliable (fit). was robust. The current situation is that the science of head • Kumho: Reliability analysis applies to all areas of expert tes- injury causation is not taught in medical schools and is not timony—scientific, technical or other specialized knowl- understood by prediatricians and other physicians who treat edge—and also to methods used, and conclusions reached, children with traumatic brain injury. The Daubert Court made in testing for litigation. it clear that the notion of general acceptance is an evolving one. Science changes and advances. This is so in the area of pediatricDaubert, Joiner and Kumho together represent the search for head injury. Therefore, one could challenge old beliefs aboutreliability as part of the quest to do justice, and are included in general acceptance and shaken baby syndrome using the argu-the now-modified Rule 702: ment that the model of shaking as a cause of traumatic brain “If scientific, technical, or other specialized knowledge will injury (TBI) in babies has never been validated by biomechani- assist the trier of fact to understand the evidence or to cians who now comprise the relevant scientific community. determine a fact in issue, a witness qualified as an expert by The main points to focus on are those of reliability and knowledge, skill, experience, training, or education, may relevancy (fit). testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the MOUNTING THE CHALLENGE TO testimony is the product of reliable principles and methods, JUNK SCIENCE IN SBS CASES and (3) the witness has applied the principles and methods reliably to the facts of the case.” There are several points of attack in so-called SBS and impact cases. First, one may challenge the mechanism or causation ofIn evaluating whether scientific or other expert testimony is injury and the timing of injury. Secondly, one may challenge theadmissible, most states follow some version of the principles application of the science to the case and the expert’s qualifica-found in either Rule 702, or a mix of the principles in Rule 702 tions.and Frye. None of the cases in the Daubert trilogy or in anystate on the admissibility of scientific evidence are shrouded in There are a number of ways to structure a challenge, but heremystery because two unifying threads are woven throughout are two suggestions. First, one can mount a general attack bytheir fabric: reliability and relevancy. No matter what the name summarizing all the faulty assumptions of causation and timingof the case or the number of the rule of evidence governing the in the medical literature, and filing a Daubert or Frye pretrialadmissibility of scientific evidence in your state, without brief forcing the State to respond with it’s own list of articles, toexception, they can all be boiled down to reliability and which one can then reply. Alternatively, or in addition to this,relevancy (fit). one can mount a specific attack by requesting all the articles upon which the State’s experts’ depend for their opinions aboutWhen science or other areas of expert knowledge are in the causation and timing. Here are some of the building blocks forcourtroom, reliability is, on a fundamental level, about trying to this type or phase of the reliability challenge.find the truth. It is about proof beyond a reasonable doubt, clearand convincing evidence or proof by a preponderance of the evi- THE BUILDING BLOCKS FOR CHALLENGING RELIABILITYdence. It is about being able to trust a result. In the area of SBS literature and opinion, there is more that is SOME IDEAS TO USE WHERE unreliable than that which is reliable. Here are a few suggestions FRYE IS NOT RETIRED for gathering the information you need in order to tell the judge the story of scientific truth in your specific case.In states where the Frye test is still the standard, developmentsin science may allow testimony to be challenged that was previ- Using state rules of criminal discovery or by motion, requestously generally accepted. For example, our evolving under- the following:standing of some of the pitfalls in fingerprint collection and 1. Any and all articles upon which the State’s experts, includ-analysis led one court to exclude evidence of latent prints as ing treaters who will testify, rely for their opinion on cau-“unreliable.”10 sation and timing. (Use the language of the indictment, grand jury testimony, and statements by the prosecutor inThere have been many advancements in the field of so-called open court about what the experts are expected to say.);shaken-baby-syndrome showing that the theory of causation and(pure shaking) is not reliable in many cases. In some cases, suchas pure impact cases, evidence of shaking is not even relevant. 2. Names of cases, names of courts and docket numbers ofShowing that the science, as it once was accepted, is no longer cases in which the State’s experts have previously testifiedgenerally accepted because it is no longer deemed reliable, is an about causation and/or timing of pediatric head injury;avenue open to those in Frye states.11 and 3. List of all articles and publications experts have written asOne can also argue that biomechanicians—who are experts in first author, second author, co-author, contributor, etc.head injury causation—comprise the relevant scientific com-munity, and not physicians. In most states, including those that As with any meaningful discovery, prepare yourself for anuse the Frye test, expert testimony about shaking causing sub- ordeal. The State, seeing you’re coming, will try to hide the ball.dural hematomas (SDH’s) and retinal hemorrhages (RH’s) was Once you have obtained as much as you can from the State, sitadmitted before the science of traumatic brain injury causation down and read it all. T H E W A R R I O R • S p r i n g 2 0 0 4 41

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THE EIGHTH CIRCLE OF FIRENote the flaws in the literature that make it unreliable. scans for purposes of establishing when injury happened. Similarly, neurosurgeons cannot agree on how to date subduralNote any inconsistencies in the experts’ positions in articles hematomas, nor can they agree on the definitions of “hypera-compared to the facts in the medical records or other materials, cute,” “acute,” “subacute,” “subchronic,” and “chronic.”such as EMT reports, that make their scientific positions irrele- Consistency and general acceptance do not exist.vant. Read every article with the doctor’s name on it. This doesnot require you to be a scientist or a physician. It does require BIAS: THE NEMESIS OF RELIABILITYsome quiet time and some common sense about what is reliableand what is not. Here are a few tips about how to read and cri- Some judges may need to become accustomed to an attack ontique the medical literature. SBS literature. “Why,” they might ask, “am I seeing this at this point in time?” It may be wise to explain in your motion and FIGHTING FIRE WITH FIRE: brief that there has been a shift to evidence-based medicine in DIAGNOSING THE ILLS OF UNRELIABILITY IN the past ten years in the medical profession, so much so that the SBS MEDICAL LITERATURE validity and reliability of medical literature in all fields of med- ical practice is now being re-evaluated and questioned.Medical experts for the State frequently base their opinion thata child was shaken and/or violently slammed, and/or that the To put this in further context, you might explain that much ofinjuries were “inflicted” within a specific time frame upon some the medical literature across the board, not just in the childof the hundreds of medical articles that have been published abuse field, that has been reevaluated suffers from the malady of bias. Indeed, bias of one sort or another has been found to beabout SBS or impact cases in the past half-century. the nemesis of reliability in most medical studies. A bias in aGetting behind these opinions in so-called SBS/impact cases is study is an error that can lead to an exaggerated or false conclu-an exercise in unraveling the literature upon which the doctor sion. Bias occurs due to faulty selection of patients or subjects,bases his or her opinion. Recall that the Kumho Court observed the way data are collected, or the way in which the authors reachthat an expert’s testimony that a proposition is accepted is not their conclusions. In the world of scientific evidence, bias equalshelpful to determine reliability “where the discipline itself lacks unreliability and exclusion.reliability.” Where the doctor’s clinical judgment regarding cau- Such problems have been amply documented. In a 1986 reviewsation and timing of injury is informed by medical literature of some 4,235 research reports on the efficacy of drug trials, sur-and medical school child abuse courses which, themselves, are gical, psychotherapeutic and diagnostic procedures—the infor-based on the same faulty literature, the doctor’s clinical judg- mation upon which our doctors rely to diagnose and treat ourment is subject to a reliability attack. Similarly, where clinical ills—three researchers concluded that only about 20 percentjudgment is based solely on a physician’s own experience, it is were valid studies.not reliable or relevant to draw conclusions about the generalforensic issues of head injury causation and timing of injury. And, don’t be fooled by the prestigious glitter of the journals. Among others, the 4,235 reports appeared in the New England INCONSISTENT CRITERIA FOR DIAGNOSIS OF SBS Journal of Medicine (NEJM), the Journal of the AmericanThe easiest way of attacking the opinion of the State’s experts is Medical Association (JAMA), the British Medical Journal (BMJ),to show that there is no general acceptance among physicians The Canadian Medical Association Journal, The Lancet, Theabout what constitutes the diagnostic criteria for so-called shak- American Journal of Psychiatry, Annals of Internal Medicine,en-baby-syndrome, or shaken-impact-baby-syndrome “S-IBS.” Archives of Neurology and Psychiatry, The Journal of Nervous and Mental Disease, and Psychiatric Quarterly.Some articles claim that SDH’s, with retinal hemorrhages, with-out external evidence of injury, are diagnostic of the syndrome. In 1985, other researchers uncovered the fact that of more thanSome authors claim that either a SDH, alone, or RH’s, alone, 200 articles in two anesthesia journals, only 15 percent wereare sufficient to make the diagnosis of SBS. Some authors claim without major errors in design and/or analysis. Some improve-that SDH’s, RH’S and broken bones, are diagnostic of the “syn- ments have been made, with peer review journal boards usingdrome.” Other authors claim that any “constellation” of the qualified statisticians and biostatisticians to review study designabove symptoms is enough to diagnose SBS, or non-accidental and check conclusions.12 But change is slow to come, and theimpact. mountain of bad science is still formidable. If the medical literature upon which our doctors rely to diag-The fact that there is no general acceptance among physicians as nose and treat us is flawed or selectively presented to us by jour-to what diagnostic criteria exist for the syndrome should be nal editors, what of the literature upon which a doctor relies inincluded in all challenges to the State’s science of causation. determining that a child was shaken or a victim of intentionalRemember that “shaken baby syndrome” is both a statement of blunt trauma, or that the injury was “inflicted” within a certaindiagnosis and causation. If there is no consensus about the diag- time frame that implicates your client? Mark Donohue, M.D.,nostic criteria, how can there be consensus about the cause? an Australian-based physician, recently reviewed the SBS med-In reading the medical literature in this area, note the lack of ical literature and concluded that “the commonly held opinionconsensus on issues relevant to the client’s case. For example, in that the finding of SDH and RH in an infant was strong evi-the area of timing of injury, neuroradiologists cannot reach con- dence of SBS was unsustainable…from the medical literature.”13sensus about how to date subdural hematomas on CT or MRI You will need to find specific examples relevant to your case to42 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIREprove this to the court by analyzing the medical literature you nificant. (Please see, “Table 1 - A Hierarchy of Strength ofobtain in discovery or through your own research. Evidence for Treatment Decisions, page 44.”) STUDY DESIGN: PITFALLS IN RELIABILITY Case-series studies do have a role in that they help medical researchers to form hypotheses, but that is as far as their useful-Once you have the articles, either from your own research ness goes. One physician recently commented:and/or as provided in pretrial discovery, crucial for evaluatingthe reliability of the methods and conclusions is to first under- “A scientist or physician who has only case reports listed instand how medical studies are classified. They are either (1) their curriculum vitae is not given much credit as aobservational or (2) experimental. Each type of study has its researcher. All it means is that they were fortunate enoughown set of potential pitfalls. In the area of SBS, fortunately, the to get a group of reportable cases, had the ability to writejob is relatively simple because there are a very limited number in the currently fashionable style and the instincts to pickof experimental studies. Most are of the less reliable, observa- and choose the journal most likely to publish their work.”15tional variety. Case-series studies should be greeted with great skepticism ifObservational studies consist of descriptive or case-series studies they claim to offer conclusions about pediatric head injury cau-(collections of case reports), case control studies, cross-sectional sation and timing of injury. Remember, case reports and stud-studies and cohort studies. ies based upon them only pose hypotheses. They do not contain science, and they are not a reliable basis for an opinion on cau- CASE-SERIES STUDIES: THE LOWEST FORM OF EVIDENTIARY sation or timing of injury. Each article should be separately cri- LIFE tiqued in the pretrial challenge to the State’s science, and each article critiqued should be attached as an exhibit to the brief soA case-series study is a simple, descriptive account of interesting that the judge, who is the reliability gatekeeper, can do his or hercharacteristics observed in a group of patients. It is one in which job.the “researchers” look at a group of cases and ask, “What hap-pened?” Because the study looks back in time, it is often called SELECTION BIASa “retrospective study.” For example, John Caffey, M.D., col- Selection bias occurs when a researcher only selects for the studylected cases of children who presented to the ER with SDH’s those examples or subjects that will support their hypothesis.and fractures of their arms and/or legs. Based on his observa- For example, a child with SDH’s and RH’s is assumed, withouttions—not experiments—Caffey wrote an article about these scientific proof, to have been a victim of shaking. (Other causescases. He concluded they had been victims of shaking without are not ruled out.) By contrast, random selection is far moreimpact.14 reliable.Most of the “observational” medical studies in the field of pedi- Australian physician Mark Donohue writes of the selection biasatric head injury and child abuse fall into this category. problem in the SBS area:According to the AMA, a mere case-series study, which involvesunsystematic clinical observations, is the least scientifically sig- “Studies and reports rely on either indirect or disputed evi- Peter Griffiths, pictured above with his prints matching the prints on a bottle of distilled water found in the ward of a childrens hospital inBlackburn, Lancashire in 1948. Griffiths kidnapped four-year-old June Devaney from her hospital bed, raped and murdered her. Griffiths was caught in the first mass registration of fingerprints in the world. More than 45,000 sets of prints were collected before Griffiths was caught, after which heconfessed. Once thought to be a foolproof method of identification, now under Daubert, even the reliability of latent (partial) fingerprint identification has come under attack. T H E W A R R I O R • S p r i n g 2 0 0 4 43

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THE EIGHTH CIRCLE OF FIRE dence of the occurrence, severity, or type of trauma. Many is a study published by the NEJM in 1998 in which four physi- studies lacking these critical data make the obvious logical cians tell us, for example, that short falls are unlikely to cause error of selecting cases by the presence of the very clinical serious trauma, citing to nine case-series studies to prove that findings and test results they seek to validate as diagnostic proposition.17 We are also told that “risk factors” for nonacci- [of the syndrome]. Not surprisingly, such studies tend to dental injury include “young parents, unstable family situations find their own case selection criteria pathognomonic [i.e., [and] low socioeconomic status” and that “fathers and diagnostic] of SBS.” boyfriends” are the two groups most likely to abuse children. These propositions are supported by citations to three articles,The problem of “indirect” or “disputed evidence” is one of each of them a case-series study, that is three articles that mere-shaky-data-syndrome. Case-series studies rely on faulty data, ly pose hypotheses, and give no reliable scientific data.such as, the confessions of parents and babysitters to shakingand, in some cases, so-called “demeanor evidence.” Confessions That most people lie when there are cases of blunt impact andto shaking are not reliable because a person might confess to serious injury is supported by cites to two case-series studies.shaking a child in an attempt to revive the child, and not with Every single one of the conclusions in this NEJM article is athe force required to cause injuries, such as, SDH’s and RH’s. A product of data dredging. There is not one original piece ofperson might even confess to shaking because in a plea negotia- research here in the text or, for the most part, cited in the foot-tion, arguably, it may be notes. If any of the State’sviewed as a less culpable and experts in a SBS case dependunderstandable stress on this summary article, orresponse compared to slam- Table 1 - A Hierarchy of Strength others like it, for causationming a child’s head against a of Evidence for Treatment Decisions or timing of injury, thiswall or other hard surface.16 should be a ground for chal- N of 1 randomized trial lenging their testimony, forHealth care workers often Single Randomized trial both their methodology andinclude demeanor evidence Systematic review of observational studies conclusions are scientificallyin the medical record, such unreliable.as, “Dad appeared to have addressing patient-important outcomesno reaction and had flat Single observational study addressing One last point of definition:affect.” The theory that a patient-important outcomes A study riddled with theflat affect is a sign of guilt is flaws of selection bias is saidnot only unreliable, it is Physiologic studies to suffer from confirmationludicrous. All people Unsystematic clinical observations bias. The easiest way to dis-respond differently to the tinguish selection bias fromshock of a loved one being This table shows the relative strengths (validity) of types of evidence presented confirmation bias is tosuddenly rushed to the hos- in medical articles utlizing evidence-based medicine (EBM). appreciate that confirmationpital. In some of the older bias is the end result of theSBS articles, demeanor evi- Looking at the hierarchy in the table, one can see that the strongest form of process of selection bias. Indence is included and some evidence is "N of 1 randomized trial," i.e., a double-blind study to test, for addressing such issues inphysicians still believe it is example, the treatment efficacy of a drug, in which one patient is tested your brief, you might wantvalid and may even “select” alternately using a placebo and a real drug, but in which neither the patient to point out that the nor the physician know which is which.the “culprit” based upon Daubert Court relied onthis. At the bottom of the rung us the lowest form of evidentiary life, i.e., "unsystem- Karl Popper for the modern atic clinical observations," of which case-series studies are the main example. day approach to scientific“Data-dredging” is another The reason case-series studies are on the bottom rung is that these are too inquiry: It should seek to fal-form of selection bias and unreliable for physicians to base their diagnoses upon and, therefore, their sify, and not confirm aoccurs when a researcher treatment decisions. Despite this, case-series studies are used as the main basis hypothesis.takes a small part of a studyand uses it to “prove” a for physicians and, utlimately, prosecutors, to accuse others of deliberately causing injury to children by violenty shaking and/or slamming their INSUFFICIENT DATApoint that the study was notdesigned to show. Data heads on hard surfaces. Case-series studies rarelydredging is often used to Table from: Article XXV, "A Users Guides to Medical Literature," by provide enough clinical dataform hypotheses but, unfor- American Medical Association, reprinted in JAMA, to allow the reader to gettunately, these are then fre- September 13, 2000, Vol 284, No. 10 behind the scientific conclu-quently presented as scien- sion and make his or hertific fact. Watch for this common problem in SBS literature. own determination about reliability. Therefore, “peer review” by fellow physicians and by pediatric head injury biomechanicians,Another form of data dredging is where an author takes a series is precluded. This flaw alone makes any study vulnerable toof case reports and tries to prove a hypothesis with these. It is attack. The question is: “Is there enough information here thatparticularly rampant in “review” articles that summarize the a physician would be able to agree with the factual foundationcontents of other SBS case-series studies. A good example of this for the diagnosis of intentionally-inflicted injury?” Work with44 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIREyour own expert or experts in determining the answer to that gen use is related to the development of breast cancer.question and, if there is insufficient data, obtain an affidavit in Hypothetical Study 2: Twenty women are divided intosupport of your reliability challenge. two groups of ten. The first ten take estrogen afterForensic Neuropathologist Jan E. Leestma, M.D., reviewed 57 menopause, and only one in this group develops breast can-articles on SBS published between 1969 and 2000. He found cer. In the second group of ten, none of whom take estro-that of 324 cases in the 57 articles, only 54 had enough data for gen, only one develops breast cancer. In Study 2, the oddsa reader to make his or her own judgment about the scientific ratio (OR) that estrogen is implicated in breast cancer isreliability of the medical conclusions regarding causation. If a 1.0, that is, it is no more likely in the first group of tenstudy does not include enough data to allow other physicians to women than in the second.analyze the validity of the methodology and conclusions, then it Hypothetical Study 3: Twenty women are divided intohas not been subject to genuine peer review, even though it has two groups of ten. In the estrogen group, one developsbeen published. breast cancer, and in the control group, two develop breast STATISTICS: A TOOL FOR cancer. By dividing two into one, the odds ratio is 0.5. In this study, it appears that women who take estrogen are THOSE WITH NO PROOF? only half as likely to develop breast cancer.With increasing frequency, physicians who write up case reports Hypothetical Study 4: Two hundred women are dividedas case-series stud- into two groupsies are attempting of 100 each. Oneto breathe scientif- hundred takeic life into these estrogen and 100lifeless corpses by do not. In theapplying statistical estrogen group,analysis. However, 14 women devel-the sample sizes in op breast cancer,case-series studies and in the con-are often too small trol group, onlyto have any statisti- 10 develop it.cal power, i.e., “sta- According to thististical signifi- study, the oddscance.” Statistical ratio is 1.4 that asignificance means woman whothat a correlation takes estrogenbetween two or will developmore factors is, breast cancer.allegedly, estab- (Compare tolished to a high Study 2 wheredegree of the odds ratio ofc e r t a i n t y . 18 developing breastStatistical signifi- cancer was 1.0.cance in a study is Science can bedevil us with its complicated terminology. But, to tell the story of scientific truth in In Study 4 thererelated to odds your case, it is crucial to become conversant with the relevant areas of science so that you can is a 4/10ths of aratios. But these empower the judge to be the reliability gatekeeper in your case. Copyright, 2004, Sidney Harris. chance greater ofvary wildly Reprinted with permission. developing breastdepending on the cancer, i.e., 1.4.)size of the sample. Hypothetical Study 5: Two hundred thousand women areMost SBS articles are based on case-series studies of small each divided into groups of 100,000. In the estrogengroups. Watch what happens to the odds ratios when the num- group, 11,000 women develop breast cancer, while in thebers are small, and then when they are large, in the following control group, only 10,000 women develop breast cancer.hypotheticals about whether estrogen causes breast cancer: According to this study, the odds ratio of developing breast Hypothetical Study 1: Twenty women are divided into cancer if one takes estrogen is 1.1. two groups of ten. The first group of ten women who are The significance of the odds ratios in Hypothetical Studies 1-5 post-menopausal take estrogen and, over their life times, is that when study samples or groups are small, the odds ratios two of them develop breast cancer. The women in the sec- jump all over the place. In small groups, the results are much ond group of women (the control group) do not take estro- more likely to be random. But, according to statisticians, the gen at all, and over their life times, only one develops breast larger the study group, the more likely it is that the odds ratio is cancer. Here the odds ratio (OR) is 2 to 1 or 2.0 that estro- real. Epidemiological data that form the basis for statistics in T H E W A R R I O R • S p r i n g 2 0 0 4 45

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THE EIGHTH CIRCLE OF FIREmedical articles depend on sample sizes that are large enough to CASE-CONTROL STUDIESbe statistically significant.19 As with case-series studies, case-control studies are retrospective.Any reliance by a physician in an SBS case on a case-series study They involve two groups: one group with the condition and onein which the ‘researchers’ applied statistics, should be attacked without, that is, the “control group.” This type of study looksas unreliable. back in time and attempts to determine what risk factors, if any, existed that caused the condition in one group, but not in the DATA-POOLING TO CONJURE control group. For example, in the area of SBS, consider the fol- UP THE ‘STATISTICS BOGEY MAN’ lowing study:Many physicians who are proponents of shaking as a cause of Group 1 consists of 10 children all of whom are said to be vic-SDH’s and RH’s have recognized the dilemma of too few sub- tims of SBS because they have SDH’s and RH’s. Group 2, thejects in too many studies and, as a way of covering their work control, are not victims of SBS. The study concludes that thewith a scientific gloss, have “pooled” what they claim is “data” children who were victims of SBS came predominantly fromfrom several different studies. This is called “meta-analysis” or single-parent homes where the parent was on welfare. However,“re-analysis.” While that might work in some areas of medical the study did not consider the other adults in the home withresearch in large, epidemiological studies, it does not work in access to the children. The conclusion of the study is that theSBS case-series studies. The simple reason for this is that, unlike “risk factors” for children being shaken are (1) a single parentsome areas of epidemiological research, the study designs in the who (2) is on public assistance.SBS literature are an inconsistent alphabet soup of mostly case- In this example, the conclusion that single parents on welfareseries studies of different specialties, such as radiology, neuro- pose a risk to children is flawed for several reasons including thesurgery and pediatrics, all of which assign different clinical failure to consider that other adults in the home may have beenmeanings to the same medical terms. These studies have differ- responsible for the alleged abuse. Studies that claim to be “case-ent group sizes, different selection criteria, different analytical control” studies should be analyzed for these types of biases.methods, and different conclusions and, of course, no con-trols.20 CROSS-SECTIONAL SURVEY STUDIESThe strength of a particular meta-analysis depends upon the Cross-sectional studies analyze data collected on a group of sub-validity of each of the studies included in the meta-analysis. The jects at one time, rather than over a longer period. They arefaulty methodology of combining cases from several case-series snapshots in time as to, “What is happening now?” For exam-studies into a larger case-review series still cannot lead to a reli- ple, a cross-sectional study might be of all defendants who con-able conclusion because case-series studies, whether large are fess to shaking a child in a particular year. Assuming they aresmall, are designed to form hypotheses, and not conclusions. In convicted for this, they complete a survey as part of a pre-sen-other words, more voodoo. tencing investigation. This type of study does not contribute toIf, when reading an article about so-called SBS, or any related defining SBS. The confessions of pure shaking without impactarea like retinal hemorrhages, you see words like “statistics,” (which may or may not be truthful in cases of plea bargaining)“statistical significance,” “odds ratio,” or “confidence interval,” bear little or no relationship to the scientific evidence on theget ready to have some fun. It is pure junk science, through and subject presented in those biomechanical studies that are scien-through, for statistics, at least in the context of case-series stud- tifically reliable.ies, truly is for those who have no real proof. (Again, think Cross-sectional studies frequently focus on issues of socio-eco-about how ludicrous it is to apply statistics to a bunch of nomic status, gender and (in some of the older ones) even raceunproved hypotheses, i.e., case-series studies.) or ethnic heritage. If the client is poor, African American, or Hispanic, some physicians may have relied on stereotypes inStatistics are also not a reliable way to determine causation in such studies in ‘selecting’ the suspect. Other studies, however,reported cases of so-called SBS. Statistics do not, in fact, prove “prove” that child abuse is not peculiar to poor people or peoplecausation. All statistical conclusions do is to report correlations. of any particular race or ethnicity. Any conclusion based on“Statistics,” said Aaron Levinson, are like bikinis. What they cross-sectional studies like these is unreliable.reveal is suggestive, but what they conceal is vital.” While “cor-relations” may be reliable enough for a toxic tort lawyer in cases COHORT STUDIESwhere social policy creates “proximate causation” to boost thecausation-in-fact proofs, statistical correlations should not help While there are no cohort studies in the SBS timing and causa-the State in criminal cases of alleged SBS or in family court pro- tion literature, it may be helpful to know what one is so that, inceedings to terminate custody or parental rights. While it is the the future, if you see one, you’ll be able to classify it. A cohortcase that statistics are not admissible in criminal cases to prove is a group of subjects that have something in common and whocausation, the fact is that the State’s physicians often rely on remain part of a group over an extended period of time. In med-faulty SBS statistical conclusions from SBS case-series studies in icine, the subjects in cohort studies are selected by some defin-forming their opinions in a case about causation and timing. As ing characteristic, such as one that is suspected of being a pre-lawyers, we need to get behind these opinions to expose their cursor to a disease.reliance on faulty, statistical foundations. A cohort might be a group of children whose genetic history46 T H E W A R R I O R • S p r i n g 2 0 0 4

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THE EIGHTH CIRCLE OF FIREputs them at risk for developing SDH’s and fractured bones as the convexities of the brain.23 A major U.S.-based neurosurgerya result of Glutaric Acidemia Types I or II. Cohort studies ask journal rejected the work. In the United States, the issue of childthe question: “What will happen?” And, because they look for- abuse is highly politicized, with supporters often receiving gov-ward, they are called “prospective” studies. They are still only ernment funding to “recognize” cases of SBS as part of a pre-observational studies and they are still subject to all the same vention program. In the UK, however, this is less the case.biases as with others of their genre. Beware of SBS studies that Following some shuttle diplomacy by an American neurosur-claim to be prospective. This is often a description that tortures geon, the article was published in 2002 in the British Journal ofthe underlying definition in order to add a gloss of (pseudo) Neurosurgery. And, in the less politically charged atmosphere ofreliability to the conclusions. the U.K., authorities there recently announced that all cases of so-called SBS are now to be reviewed to determine if some peo- PUBLICATION BIAS ple were wrongly convicted.24State experts sometimes claim that there are relatively few stud-ies in the medical literature that challenge SBS as a cause of EXPERIMENTAL STUDIESSDH’s and RH’s. This is frequently used as a way of diminish- These are studies in which researchers, having formed hypothe-ing and characterizing the ses from observational studies,defense experts as those who are set out to test them. One factmere “mavericks” or who are on that speaks volumes about thisthe fringe of the medical estab- area is that there are a limitedlishment.21 number of these in the SBS liter- ature. This state of affairs shouldThis is the time to raise the issue be brought to the trial judge’sof publication bias. Many articles attention to underscore the factthat present unreliable science that case-series studies and otherstill slip through the cracks of the observational studies merelyboards of peer review journals present unproved and untestedand those that present science hypotheses about causation andcontrary to popular belief are timing of injury. As discussed inmore likely to be rejected. Take Parts I and II of this series, twoDr. Atkins and his low-carb diet, of the best known experimentalfor example. His efforts to get his studies show that by shaking,message out were hindered by the alone, a human being is notAmerican Medical Association capable of generating the forces(AMA) and the American Heart necessary to produce SDH’s, dif-Association (AHA) that saw his fuse axonal injury (DAI) anddiet as dangerous to their low-fat concussion.dogma.One medical examiner recently THE PIPER AT THE GATES OFlamented: DAWN Even though human biases are In Graham Greene’s “The Wind inevitable, they become dogma in the Willows,” two of the because the medical elite story’s charming little river crea- accepts, appropriates and then tures, Ratty and Mole, are just perpetuates them. Research to about to turn in for the night the opposite is not funded, Ratty and Mole venture into the night to find the lost child treas- after a long, summer’s day. But cannot be published and, if it ured by all as a gift. Do not be afraid to venture into the night to Ratty cannot sleep, plagued as he does see the light of print, recover and seize the scientific truth for your client. is with worry about the son of ridiculed and pooh poohed ‘til his friend, Otter. The child, at times it causes the loss of the researcher’s career. Journals Portly, has been missing for too long to be just off playing some- are not pure and scientific, but only reflect the biases of the where in a self-possessed and absent-minded way. Otter is editorial boards, which means the power elite in the afraid, and now Ratty is, too, that the baby Otter—who hasn’t field.”22 yet learned to swim—has been sucked up in the fast flow of a local ford, a place for which the child has an insatiable fascina-It is still extremely difficult to get any of the major journals to tion. Instead of going to sleep, Ratty and Mole set off into thepublish articles that refute the common and erroneous beliefs in night in their rowboat along the moonlit river in search of theso-called shaken baby syndrome. missing child.In 2002, Ommaya and colleagues attempted to publish a major Their journey is long and treacherous through the shadows andreview article that included some of the medical and biome- unfamiliar shapes of the now-darkened land. Then, as the pinkschanics data that challenged shaking as the cause of SDH’s over T H E W A R R I O R • S p r i n g 2 0 0 4 47

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THE EIGHTH CIRCLE OF FIREand oranges of the sky declare themselves on the dawn’s horizon, 6 See, e.g., United States v Llera Plaza, 2000 W.L 27305 (E.D.Ratty and Mole hear the magical and enchanting sound of pipe Pa., Jan, 2002), in which the court notes that the Frye test wasmusic. Drawn hypnotically to this, they row their boat closer applied to all science in the federal courts.and, as they do so, are drawn to a small island midstream from 7 See, e.g., State v Porter, 241 Conn. 57 (1997), in which thewhich a bright light is getting blindingly brighter by the second. Connecticut Supreme Court discusses the history of theThey pull to shore and, blinking in the blaze of light, step onto Connecticut judiciary’s independence from the scientific worldthe island where they are greeted by a heavenly being with pipes in evaluating the reliability of evidence proffered as “scientific.”in hand. Between the toes of this great shining, holy being, thebaby otter, Portly, slumbers peacefully in safe oblivion. Then the 8 Amici briefs from some of the heavy hitters in the scientificPiper at the gates of dawn smiles kindly at the brave little river community included: American Association for thecreatures that came out in the night to find the lost baby otter. Advancement of Science (AAAS) with the National AcademyAnd with that smile, Portly, the precious otter child, is returned of Sciences, The New England Journal of Medicine (NEJM),to those that love and treasure him as a gift. Annals of Internal Medicine, the Carnegie Commission for Science, Technology and Government, and Physicians,As with a gift that has been returned to us, the power to decidewhat is reliable is now returned to the hands of trial judges. But Scientists and Historians of Science.that means we lawyers must work hard to discover the nuggets 9 A discussion of the development of scientific thought up toof scientific truth, and to expose unreliable science in our oppo- and beyond Popper is included in Part I of this series, “Thenent’s case, to become so conversant with the scientific issues Elephant on the Moon,” The WARRIOR, Fall 2003. Please seethat we are able to help guide the judge, by briefing, by profi- endnote 1, above, for information about how to obtain this.cient direct and cross examination of experts in pretrial Daubert 10 See, endnote 6, above, in which one court discusses this devel-hearings or through affidavits, to reach a just result based on opment.reliable and relevant science. This article suggested a few guide- 11 See, Part I, “The Elephant in the Moon,” and Part II, “Alines to get started on that journey in SBS cases. You will no Matter of Gravity,” and endnote 1, above.doubt discover many areas of faulty methodology and conclu-sions in your own cases. Do what you can to keep it simple, 12 See, generally, Dawson-Saunders, B., and Trapp, R.G., “Basicfocusing on reliability and relevancy to get at the scientific truth and Clinical Biostatistics,” Appleton & Lange, Chapter 1,in each case. The piper at the gates of dawn has returned to us (hereafter “Biostatistics”).the lost power to do justice. It is time now to use it for our 13 Donohue, M., M.D., Am J For Med & Path, Vol 24, No. 3, ppclients. q 239-242, Sept. 2003, at 241. 14 See, Part I, “The Elephant in the Moon,” and endnote 1, ENDNOTES above.1 Part I of this series, “The Elephant on the Moon,” The WAR- 15 Confidential communication. RIOR, Fall 2003, and Part II, “A Matter of Gravity,” may be 16 This is discussed in Part I: “The Elephant in the Moon.” See obtained directly from the journal. Go to www.triallawyerscol- endnote 1, above. lege.com for the current address. Both Parts I and II may also 17 Duhaime, et al, “Nonaccidental Head Injury in Infants—The be obtained as PDF’s (and viewed using Adobe Acrobat ‘Shaken Baby Syndrome,’” NEJM, Vol. 338, No. 25, pp 1822- Reader) from the author’s web site at www.sharplaw.biz. All 29, June 18, 1998. rights reserved. 18 This degree of certainty is called a “confidence interval” or CI2 This is part of a book currently being written by Elaine and, as it involves some complicated calculations that are not Whitfield Sharp. Copyright by Elaine Whitfield Sharp, helpful here, this will not be discussed further. For further January, 2004. Permission to publish given to The WARRIOR. reading in this, see, Milloy, S.J., Junk Science Judo, Cato3 Daubert v Merrell Dow Pharmaceuticals, 509 US 579, 113 Institute, and Biostatistics, cited supra. S.Ct. 2786 (1993). Daubert’s progeny includes: General 19 At least one author claims that big numbers result in big lies. Electric Company v Joiner, 522 U.S. 136, 118 S. Ct. 512 See, Milloy, supra. (1997) (“Joiner”); and Kumho Tire Co. v Carmichael, 526 20 A “control” is a group that does not share the condition being U.S. 137, 119 S.Ct 1167 (1999) (“Kumho”). Further citation studied. to these cases is to the official reporters. 21 Let us not forget that, in their own time, Hipprocrates, Galileo4 Frye v United States, 54 App. D.C. 46, 293 F. 1013 (D.C. Cir. and Sir Isaac Newton were all mavericks. 1923), (“Frye”). 22 Confidential communication.5 Mr. Frye was ultimately exonerated and released when excul- patory evidence came to light. However, the systolic blood 23 Ommaya, A.K, M.D., et al, “Biomechanics and neu- pressure test, which spawned the polygraph, did not fare so ropathology of adults and paediatric heady injury,” BJN, 2002; well. In 2002, the National Academy of Sciences issued a 16(3): 220-224. report concluding that the lie-detector test was not reliable sci- 24 The Times, (London) January 26, 2004, p 4, “Shaken-baby ence. death cases to be reviewed.”48 T H E W A R R I O R • S p r i n g 2 0 0 4